And here we are with the 4th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:

#1 Cardiac Arrest

#2 Airway Management

In this episode we’ll explore the best articles of 2014 about:

Stroke

Before starting we have to declare (if you are not aware of) that MEDEST is quite skeptical about the previous studies that are at the basis of thrombolytic therapy (Lo strano caso del trombolitico nell’ictus cerebrale ischemico, Pubblicate le nuove linee guida AHA/ASA sul trattamento precoce dello Stroke: nessuna nuova ed ancora qulache dubbio!, L’uso del trombolitico nello stroke. Stiamo giocando con la salute dei nostri pazienti?, rt-PA e Stroke: IST-3 l’analisi dei risultati). This can represent a potential bias on the choice of the articles. We also think that the actual evidences, and the consequent guidelines, are strongly influenced by commercial interests and not well supported from evidences that demonstrates how benefits outweight harms. We hope that 2015 will be the first year of a new era for stroke management, an era of well done studies producing strong evidences to achieve good neurological targets in all stroke patients.

In the first part we mention the litterature about thrombolytic therapy

• Thrombolytic Therapy in  Acute Stroke
• Questions about authorisation of alteplase for ischaemic stroke
• Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative
• Time to treatment with recombinant tissue plasminogen activator and outcome of stroke in clinical practice
• Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials
• Association Between Hyperoxia and Mortality After Stroke- A Multicenter Cohort Study

And then the articles about endovascular therapy:

• A meta-analysis of prospective randomized controlled trials evaluating endovascular therapies for acute ischemic stroke
• A research roadmap of future endovascular stroke trials
• Endovascular therapy for acute ischemic stroke is indicated and evidence based: a position statement
• Reperfusion therapies of acute ischemic stroke: potentials and failures
• Stroke- an emphasis on guidelines
• A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke
• Prehospital Stroke Care: Limitations of Current Interventions and Focus on New Developments

And now as anticipated in the title the 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department. Those freshly published guidelines give answer at two of most recurrent questions on stroke treatment:

1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?

2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?

Download and read the full policy to discover the recommendations made and based on the strength of the available data.

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.

Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).

So download the full text and read it carefully to have a clear and complete opinion of the related topics.

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Tag:ACR, advanced airway management, Antiaggregazione, antiplatelets, arresto cardiaco, clinical decision rules, emergency medicine, emergenza sanitaria territoriale, gestione avanzata delle vie aeree, litterature review, medicina d'urgenza, prehospital emergency medicine, sindromi coronariche acute, Stroke

And here we are with the 3th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:

#1 Cardiac Arrest

#2 Airway Management

In this episode we’ll explore the best articles of 2014 about:

Trauma

Before approaching specific arguments about trauma here are some fundamental articles to read about new emerging concepts in trauma care. Those are the clinical and physiological bases to understand what is happening in the actual trauma management scene.

• Trauma-Induced Coagulopathy

  • Pre-hospital identification of trauma patients with  early acute coagulopathy and massive bleeding:  results of a prospective non-interventional clinical  trial evaluating the Trauma Induced Coagulopathy  Clinical Score (TICCS)

• Development of a simple algorithm to guide the effective management of traumatic cardiac arrest  (read also Mind of resuscitation in traumatic cardiac arrest)

• Damage Control Resuscitation in Trauma

• The Management of Pediatric Polytrauma: Review

And now let’s go to specific area of interest:

• Spine immobilization

Spine immobilization in trauma is changing.

After years of dogmatic approach to strict spine immobilization for all trauma patients regardless any other factor, is now pretty clear that not all the trauma patients benefits from this all or nothing way of thinking. MEDEST already faced the argument in previous posts (The Death of the Cervical Collar?) as also did some prehospital consensus guidelines (Faculty of Pre-Hospital Care Consensus Statements).

In 2014 many articles treated this topic in a critical and modern way of re-thinking spinal immobilization, in particular the widespread use of cervical collar. The lessons we learned is that:

1. Widespread use of cervical collar in neck trauma has to be carefully evaluated (and even avoided) due to the low incidence of unstable spinal lesions.
2. Routine use of cervical collar is of unclear benefit and supported by weak evidences. A new selective approach has to be implemented based on prehospital clearance protocols.

• Cost-utility analysis of prehospital spine immobilization recommendations for penetrating trauma

• Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma

• Prehospital Use of Cervical Collars in Trauma Patients- A Critical Review

• Comparison of Three Prehospital Cervical Spine Protocols  for Missed Injuries

• Fluids and blood products

What is “revolution” in clinical practice? We don’t have the answer to this dilemma, but what is happening in fluid resuscitation for trauma patients seems likely to be revolutionary. Restrictive strategies and new blood products are the future for the treatment of trauma patients (read also Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?).

• Liberal Versus Restricted Fluid Resuscitation Strategies in Trauma Patients

• Fluid resuscitation in trauma patients- what should we know

• Pretrauma Center Red Blood Cell Transfusion Is Associated With Reduced Mortality and Coagulopathy in Severely Injured Patients With Blunt Trauma

• The Ongoing Debate Between Crystalloid and Colloid

• Fluid Resuscitation for Trauma Patients: Crystalloids Versus Colloids

• Hypotensive Resuscitation

• Trauma and Massive Blood Transfusions

• Is early transfusion of plasma and platelets in higher ratios associated with decreased in-hospital mortality in bleeding patients?

• The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study

But much more happened in 2014 about trauma….

Resuscitative throacotomy is now a reality not only “in” but even “out” of hospital, so read all about it

• Resuscitative thoracotomy an update

An evergreen topic is TBI but new concepts are arousing so read here the latest updates

• Critical care management of severe traumatic brain injury in adults

New drugs and new protocols for airway and pain management: a rationale guide to choose the right drug for the right patient.

• Choice of General Anesthetics for Trauma Patients

• Pain   management   in   trauma   patients   in   (pre)hospital   based emergency   care:   Current   practice   versus new guideline

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.

Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).

So download the full text and read it carefully to have a clear and complete opinion of the related topics.

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Tag:ACR, advanced airway management, Antiaggregazione, antiplatelets, arresto cardiaco, clinical decision rules, emergency medicine, emergenza sanitaria territoriale, gestione avanzata delle vie aeree, litterature review, medicina d'urgenza, prehospital emergency medicine, sindromi coronariche acute, Stroke

This is the first (of a series) of literature reviews dedicated to a particular topic of Emergency Medicine clinical life.

We tried to give a deep look to all the articles that had a relevance for a particular argument in this year, and made some considerations regarding the emerged evidences . All the articles are full text end ready to be downloaded.

The first edition is focused on the “king argument” for an emergency medicine and critical care professional:

Cardiac Arrest

Chest compressions

This year the importance of chest compressions in CA was confirmed and even emphasized as one of the few (along with defibrillation) really wothy intervention to perform during CPR.

• Chest Compression Alone Cardiopulmonary Resuscitation Is Associated With Better Long-Term Survival Compared with Standard Cardiopulmonary Resuscitation
• Chest compression depth and survival in out-of-hospital cardiac arrest

Mechanical Devices

The “black year” for mechanical devices saw 3 major trials finding no difference in outcome between mechanical and (good quality) manual chest compressions. Still remains the subjective (personal) impression that mechanical devices are of some utility for the human resources management and  transport during CPR.

• Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial
• Mechanical chest compressions and simultaneous defibrillation-vs-conventional cardiopulmonary resuscitation in-out-of-hospital cardiac arrest The LINC RCT
• Do Mechanical Devices Improve Return of Spontaneous Circulation Over Manual Chest Compressions in Out-of-Hospital Cardiac Arrest
• Prehospital Randomized Assessment of a Mechanical Compression Device in Cardiac Arrest (PARAMEDIC)

Vasoactive (and other) drugs

Like (and perhaps more) than for mechanical devices, 2014 signed a really bad year for epinephrine.

Lack of evidence on his utility and emerging ones on detrimental effects, accompanied this “historical” drug through the year that preludes to new 2015 CA Guidelines. Will epinephrine still be there at the end of this 2015? Or new emerging trends on use of steroids and vasopressin will prevale at the end?

• Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest
• Epinephrine, vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy?
• Glucocorticoids as an Emerging Pharmacologic Agent for Cardiopulmonary Resuscitation
• Epinephrine in Cardiac Arrest and Patients Outcomes
• Adrenaline for out-of-hospital cardiac arrest resuscitation- A systematic review and meta-analysis of randomized controlled trials
• Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest- A retrospective review of prospectively collected data
• Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry
• Does Calcium Administration During Cardiopulmonary Resuscitation Improve Survival for Patients in Cardiac Arrest?

ECLS

And after interventions that are loosing evidence in the years, new future prospectives for the management of CA patients, comes from Extra-Corporeal Membrane Oxygenation that gives renewed hopes of better survival and good neurological outcome, despite initial difficulties and skepticism.

• Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest- A prospective observational study
• An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest- a propensity-matched study

Outcome and prognostication

• Exploring which patients without return of spontaneous circulation following ventricular fibrillation out-of-hospital cardiac arrest should be transported to hospital
• Predicting the lack of ROSC during pre-hospital CPR- Should an end-tidal CO 2 of 1.3 kPa be used as a cut-off value
• Shorter time until return of spontaneous circulation is the only independent factor for a good neurological outcome in patients with postcardiac arrest syndrome
• Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study
• Trends in Short- and Long-Term Survival Among Out-of-Hospital Cardiac Arrest Patients Alive at Hospital Arrival
• Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest
• Angiography Urged in All Resuscitated Out-of-Hospital Cardiac Arrest

Therapeutic Hypothermia

New era for the post-resuscitative care! Less oxygen, lower tidal volume and last, but not least, less cooling. And, while this year will give us some answers about intra-arrest cooling, now we know that 33°C is equally effective as 36°C and is no longer recommended in post ROSC patients! Maybe….

• Effect of Prehospital Induction of Mild Hypothermia on Survival andNeurological Status Among Adults With Cardiac Arrest A Randomized Clinical Tria.pdf
• Targeted Temperature Management Processes and Outcomes After Out-of-Hospital Cardiac Arrest- An Observational Cohort Study
• From therapeutic hypothermia towards targeted temperature management: a decade of evolution

Other

Hypotermia (accidental not therapeutic), highlights from ERC 2014 Congress and decision on non starting CPR: what changes and what remains in our daily practice.

• Cardiac arrest from accidental hypothermia, a rare condition with potentially excellent neurological outcome, if you treat it right
• Resuscitation highlights- Part 1
• Resuscitation highlights- Part 2
• Current Opinion in Critical Care-Cardica Arrest
• Decisions Relating To CPR
• Hemodynamic–directed cardiopulmonary resuscitation during in–hospital cardiac arrest

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.

Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).

So download the full text and read it carefully to have a clear and complete opinion of the related topics.

Follow MEDEST on Google+

Follow MEDEST on Facebook

Clicca su MEDEST e scopri chi siamo

Tag:ACR, advanced airway management, Antiaggregazione, antiplatelets, arresto cardiaco, clinical decision rules, emergency medicine, emergenza sanitaria territoriale, gestione avanzata delle vie aeree, litterature review, medicina d'urgenza, prehospital emergency medicine, sindromi coronariche acute, Stroke

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.

Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).

So download the full text and read it carefully to have a clear and complete opinion of the related topics.

The latest Review of the year is dedicated to a collection of the most important (for us) articles of this 2014.

This is MEDEST way to wish you all Merry Xmas.

Enjoy the reading:

Cardiac Arrest

Chest compression

• Chest Compression Alone Cardiopulmonary Resuscitation Is Associated With Better Long-Term Survival Compared with Standard Cardiopulmonary Resuscitation
• Chest compression depth and survival in out-of-hospital cardiac arrest

Mechanical Devices

• Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial
• Mechanical chest compressions and simultaneous defibrillation-vs-conventional cardiopulmonary resuscitation in-out-of-hospital cardiac arrest The LINC RCT
• Do Mechanical Devices Improve Return of Spontaneous Circulation Over Manual Chest Compressions in Out-of-Hospital Cardiac Arrest

Vasoactive drugs

• Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest
• Epinephrine, vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy?
• Glucocorticoids as an Emerging Pharmacologic Agent for Cardiopulmonary Resuscitation
• Adrenaline for out-of-hospital cardiac arrest resuscitation- A systematic review and meta-analysis of randomized controlled trials
• Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest- A retrospective review of prospectively collected data
• Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry
• Does Calcium Administration During Cardiopulmonary Resuscitation Improve Survival for Patients in Cardiac Arrest?

ECLS

• Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest- A prospective observational study
• An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest- a propensity-matched study

Outcome and prognostication

• Exploring which patients without return of spontaneous circulation following ventricular fibrillation out-of-hospital cardiac arrest should be transported to hospital
• Predicting the lack of ROSC during pre-hospital CPR- Should an end-tidal CO 2 of 1.3 kPa be used as a cut-off value
• Shorter time until return of spontaneous circulation is the only independent factor for a good neurological outcome in patients with postcardiac arrest syndrome
• Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study
• Trends in Short- and Long-Term Survival Among Out-of-Hospital Cardiac Arrest Patients Alive at Hospital Arrival
• Early coronary angiography and induced hypothermia are associated with survival and functional recovery after out-of-hospital cardiac arrest
• Angiography Urged in All Resuscitated Out-of-Hospital Cardiac Arrest

Therapeutic Hypothermia

• Effect of Prehospital Induction of Mild Hypothermia on Survival andNeurological Status Among Adults With Cardiac Arrest A Randomized Clinical Tria.pdf
• Targeted Temperature Management Processes and Outcomes After Out-of-Hospital Cardiac Arrest- An Observational Cohort Study
• From therapeutic hypothermia towards targeted temperature management: a decade of evolution

Other

• Cardiac arrest from accidental hypothermia, a rare condition with potentially excellent neurological outcome, if you treat it right
• Resuscitation highlights- Part 1
• Resuscitation highlights- Part 2
• Current Opinion in Critical Care-Cardica Arrest
• Decisions Relating To CPR
• Hemodynamic–directed cardiopulmonary resuscitation during in–hospital cardiac arrest

Trauma

Spine immobilization

• Cost-utility analysis of prehospital spine immobilization recommendations for penetrating trauma
• Learning the lessons from conflict- Pre-hospital cervical spine stabilisation following ballistic neck trauma
• Prehospital Use of Cervical Collars in Trauma Patients- A Critical Review
• Comparison of Three Prehospital Cervical Spine Protocols  for Missed Injuries

Fluids and blood products

• Liberal Versus Restricted Fluid Resuscitation Strategies in Trauma Patients
• Fluid resuscitation in trauma patients- what should we know
• Pretrauma Center Red Blood Cell Transfusion Is Associated With Reduced Mortality and Coagulopathy in Severely Injured Patients With Blunt Trauma
• The Ongoing Debate Between Crystalloid and Colloid
• Fluid Resuscitation for Trauma Patients: Crystalloids Versus Colloids
• Hypotensive Resuscitation
• Trauma and Massive Blood Transfusions
• Is early transfusion of plasma and platelets in higher ratios associated with decreased in-hospital mortality in bleeding patients?
• The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study

Other

• Resuscitative thoracotomy an update
• Critical care management of severe traumatic brain injury in adults
• Choice of General Anesthetics for Trauma Patients
• Development of a simple algorithm to guide the effective management of traumatic cardiac arrest
• Damage Control Resuscitation in Trauma
• Trauma-Induced Coagulopathy
• Pre-hospital identification of trauma patients with  early acute coagulopathy and massive bleeding:  results of a prospective non-interventional clinical  trial evaluating the Trauma Induced Coagulopathy  Clinical Score (TICCS)
• Pain   management   in   trauma   patients   in   (pre)hospital   based emergency   care:   Current   practice   versus new guideline
• The Management of Pediatric Polytrauma: Review

Airway management

• Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury
• Avoiding Circulatory complications during Intubation
• Regarding Hemodynamic Responses During Orotracheal Intubation: A Randomized Controlled Trial
• Apnoea and pre-oxygenation
• Delayed Sequence Intubation: A Prospective Observational Study
• Advanced Airway Management Simulation Training in Medical Education- A Systematic Review and Meta-Analysis
• Surgical Management Of the Failed Airway: A Guide To Percutaneous Cricothyrotomy
• Airway management and out-of-hospital cardiac arrest outcome in the CARES registry
• Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians
• Outcomes following prehospital airway management in severe traumatic brain injury

Sepsis

• Severe Sepsis and Septic Shock
• A Randomized Trial of Protocol-Based Care for Early Septic Shock
• Evaluation of 7.5 years of Surviving Sepsis Campaign Guidelines
• Goal-Directed Resuscitation for Patients with Early Septic Shock

ACS

• Pretreatment with Prasugrel in Non–ST-Segment Elevation Acute Coronary Syndromes
• Unfractionated Heparin vs Bivalirudin in Primary PCI- The HEAT – PPCI Trial
• ATLANTIC Prehospital Ticagrelor in ST-Segment Elevation Myocardial Infarction
• Reappraisal of thienopyridine pretreatment in patients with non-ST elevation acute coronary syndrome: a systematic review and meta-analysis

• Validation of an accelerated high-sensitivity troponin T assay protocol in an Australian cohort with chest pain
• Myocardial infarction (acute): Early rule out using high sensitive troponin
• The Manchester Acute Coronary Syndromes (MACS) decision rule for suspected cardiac chest pain derivation and external validation

• Third Universal Definition of Myocardial Infarction
• Efficacy and Safety of Out-of-Hospital Intravenous Metoprolol Administration in Anterior ST-Segment Elevation Acute Myocardial Infarction

Stroke

• Thrombolytic Therapy in  Acute Stroke
• Questions about authorisation of alteplase for ischaemic stroke
• Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative
• Time to treatment with recombinant tissue plasminogen activator and outcome of stroke in clinical practice
• Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials
• A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke
• Prehospital Stroke Care: Limitations of Current Interventions and Focus on New Developments
• Association Between Hyperoxia and Mortality After Stroke- A Multicenter Cohort Study

Guidelines

• AHA:ASA Guideline on Stroke With Brain Swelling
• Clinical practice guideline on diagnosis and treatment of hyponatraemia
• GOLD Report 2014
• 2014 AHA/ACC  Atrial Fibrillation Guidelines
• 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
• 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism
• Guideline on Treatment of Patients with Severe and Multiple Injuries
• The Japanese guidelines for the management of sepsis

Emergency Pharmacology

• Lorazepam vs Diazepam for Pediatric Status Epilepticus
• The Effect of Ketamine on Intracranial and Cerebral Perfusion Pressure and Health Outcomes- A Systematic Review
• Prehospital analgesia using nasal administration of S-ketamine – a case series
• Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients
• Anaphylaxis Is More Common with Rocuronium and Succinylcholine than with Atracurium
• Anaphylaxis to Neuromuscular-blocking Drugs: All Neuromuscular-blocking Drugs Are Not the Same
• Tranexamic Acid for Patients With Traumatic Brain Injury A Randomized, Double-Blinded, Placebo-Controlled Trial

Mechanical Ventilation

• Effect of Out-of-Hospital Noninvasive Positive-Pressure Support Ventilation in Adult Patients With Severe Respiratory Distress- A Systematic Review and Meta-analysis
• Prehospital Noninvasive Ventilation for Acute Respiratory Failure
• Sedation in non-invasive ventilation: do we know what to do (and why)?
• Tidal Volume and Mortality in Mechanically Ventilated Children- A Systematic Review and Meta-Analysis of Observational Studies
• Lung protection strategy as an effective treatment in acute respiratory distress syndrome

Other clinical conditions

• Effect of prehospital ultrasound on clinical outcomes of non-trauma patients—A systematic review
• Rate- and rhythm-control therapies in patients with atrial fibrillation- a systematic review
• Validation of a New Coma Scale, the FOUR Score, in the Emergency Department
• Anaphylaxis
• Fluid resuscitation in acute medicine: what is the current situation
• Treatment for calcium channel blocker poisoning- A systematic review

Non Clinical

• Free Open Access Medical education (FOAM) for the emergency physician
• Five Strategies to Effectively Use Online Resources in Emergency Medicine
• Open Access to Clinical Trials Data
• Revised standards for statistical evidence

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Tag:ACR, advanced airway management, Antiaggregazione, antiplatelets, arresto cardiaco, clinical decision rules, emergency medicine, emergenza sanitaria territoriale, gestione avanzata delle vie aeree, litterature review, medicina d'urgenza, prehospital emergency medicine, sindromi coronariche acute, Stroke